NCLEX Neuro Disorders

the nurse is assisting in caring for a client with a supratentorial lesion. the nurse monitors which criterion as the critical index of CNS dysfunction?

LOC rationale LOC is the most critical index of CNS dysfunction. changes in LOC can indicate clinical improvements or deterioration. although blood pressure, temperature and ability to speak may be components of the assessment, the client LOC is the most critical index of CNS dysfunction

the nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. the nurse understands that an early sign of rupture is which?

a decline in LOC rationale rupture of a cerebral aneurysm usually results in increased ICP. the first sign of pressure is a change in the LOC because of compression of the reticular formation in the brain. this change in LOC can be as subtle as drowsiness or restlessness. because centers that control BP are located lower in the brainstem than those that control consciousness, changes in pulse pressure are a later sign.

an 84-year-old client in an acute state of disorientation was brought to the ED by the clients daughter. the daughter states that this is the first time that the client experienced confusion. the nurse determines from this piece of information that which is unlikely to be the cause of the client's disorientation?

Alzheimers disease rationale AD is a chronic disease with progression of memory deficits over time. the situation presented in the question represents an acute problem. medication use, hypoglycemia and impaired cerebral circulation require evaluation to determine if they play a role in causing the client's current symptoms.

the clinic nurse is reviewing the medical record of a client scheduled to be seen in the clinic. the nurse notes that the client is prescribed selegiline hydrochloride (Eldepryl). the nurse understands that this medication is prescribed for which diagnosis?

Parkinson's disease rationale selegiline hydrochloride is an antiparkinsonian medication. the medication increases dopaminergic action, assisting in the reduction of tremor, akinesia, and the rigidity of parkinsonism. this medication is not used to treat CAD, diabetes mellitus or alzheimer's disease.

an adult client had a CSF analysis after LP. the nurse interprets that a negative value of which is consistent with normal findings?

Red blood cells rationale the adult with normal CSF has no red blood cells in the CSF. the client may have small levels of white blood cells (0-3 per mm3) protein (15-45 mg/dL) and glucose (40-80 mg/dL) are normally present in CSF

a client in the ED is diagnosed with Bell's palsy. the nurse collecting data on this client expects to note which observation?

a lag in closing the bottom eyelid rationale the facial drooping associated with Bell's palsy makes it difficult for the client to close the eyelid on the affected side. a widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell's palsy. paroxysms of excruciating pain are seen with trigeminal neuralgia

a client with MG becomes increasingly weaker. the HCP injects a dose of Enlon to determine whether the client is experiencing a myasthenic crisis or a cholingeric crisis. the nurse expects that the client will have which reaction if the client is in cholinergic crisis?

a temporary worsening of the condition rationale Enlon is a short-acting acetlycholinesterase inhibitor used to diagnose MG or differentiate between myasthenic or cholinergic crisis. an enlon injection makes the client in cholinergic crisis temporarily worse, known as a negative enlon test

a client with spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. which is the best response by the nurse?

acknowledge the clients anger and continue to encourage participation in care rationale adjusting to paralysis is difficult both physically and psychosocially for the client and family. the nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. the nurse acknowledges the clients feelings while continuing to meet the clients physical needs and encouraging independence

the nurse is preparing a client who is scheduled to have cerebral angiography performed. which should the nurse check before the procedure?

allergy to iodine or shellfish rationale the client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish. (allergy to salmon is not associated with this procedure. claustrophobia and excessive weight are areas of concern with MRI)

the nurse has obtained a personal and family history from a client with a neurological disorder. which finding in the client's history is least likely associated with a risk for neurological problems?

allergy to pollen rationale previous neurological problems such as headaches or back injuries place the client more at risk for development of a neurological disorder. chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. assessment of allergies is a routine part of the health history, regardless of the nature of the client's problem. in addition, an allergy to pollen would not place the client at risk for a neurological problem.

the nurse assisting in the care of a client who is being evaluated for possible myasthenia gravis. the HCP gives a test done of edrophonium (Enlon). the nurse recalls that the client should have which reaction if the client has this disease?

an increase in muscle strength within 1 to 3 minutes rationale Enlon is a short-acting acetylcholinestrase inhibitor used to diagnose MG. an increase in muscle strength should be seen in 1 to 3 minutes following the test dose if the client does have the disease. if no response occurs, another dose is given over the next 2 minutes and muscle strength again is tested. if no increase in muscle strength occurs with this higher dose, the muscle weakness is not caused by MG. clients who receive injections of this medication commonly demonstrate a drop in blood pressure, feel faint and dizzy and are flushed

which information will the nurse reinforce to the client scheduled for a LP

an informed consent will be required rationale client preparation for LP includes obtaining informed consent from the client. no dietary or food restrictions are required before the test. the client is told that the test will take approximately 15 to 60 minutes. the nurse needs to inform the client about the need to bed rest following the test

the nurse is monitoring a client with a spinal cord injury for signs of spinal shock. which signs is indicative of this complication of a spinal cord injury?

areflexia below the level of injury rationale spinal shock represents a temporary but profound disruption of spinal cord function which occurs immediately after injury and is clinically evident within 30 to 60 minutes. it is a state of areflexia characterized by the loss of all neurological function below the level of injury. flaccid paralysis, bradycardia and hypotension occur. the body is unable to use either shivering or perspiring as a means of controlling body temperature.

the nurse is ambulating a client with a known seizure disorder. the client says, i'm seeing those flashing lights again, then loses consciousness and develops a clonic-tonic seizure. which would be the nurse's initial action?

assist the client to the floor rationale assisting the client to the floor is the initial action to prevent client injury. inserting an oral airway may actually cause harm to the client and no item should be inserted into the clients mouth during a seizure. administering a dose of phenytoin requires HCP prescription and would not be the first action. stat paging the HCP would not be the first action.

the nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. the nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization?

associated with poor comprehension rationale global aphasia is a condition in which a person has a few language skills as a result of extensive damage to the left hemisphere. the speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. the client with conduction aphasia has difficulty repeating words spoken by another, and the speech is characterized by literal paraphasia with intact comprehension. the client with Wernicke's aphasia may exhibit a rambling type of speech

the nurse is preparing a plan of care for a client with a brain attack (stroke) who has global aphasia. the nurse incorporates communication strategies in the plan of care, knowing that the client's speech should fit which characterization?

associated with poor comprehension rationale global aphasia is a condition in which a person has few language skills as a result of extensive damage to the left hemisphere. the speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. the client with conduction aphasia has difficulty repeating words spoken by another and the speech is characterized by literal paraphasia with intact comprehension. the client with Wernicke's aphasia may exhibit a rambling type of speech

the nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. which would indicate a basal skull fracture as a result of the injury

blood or clear drainage from the auditory canal rationale bloody or clear watery drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture. this warrants immediate attention.

the nurse is monitoring a client with a C5 spinal cord injury for spinal shock which findings would be associated with spinal shock in this client? select all that apply

bowel sounds are absent // the client's abdomen is distended // respiratory excursion is diminished // accessory muscles of respiration are areflexic rationale during the period of areflexia that characterizes spinal shock, the BP may fall when the client sits up. the bowel and bladder often become flaccid, may become distended, and fail to empty spontaneously. bowel sounds would be absent. accessory muscles of respiration may become areflexic as well, diminishing respiratory excursion and oxygenation

the nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. which diagnostic test should be prescribed to confirm this diagnosis?

brain biopsy rationale the diagnosis of herpes simplex encephalitis can be made by brain biopsy and is rarely made from the culture of cerebrospinal fluid obtained from a lumbar puncture. the EEG is abnormal, in many cases, indicating temporal lobe abnormalities, but it will not confirm the diagnosis. the CT scan is normal up to the first 5 days, with low-density lesions in the temporal lobe noted later

a client with Parkinson's disease is developing dementia. which action should the nurse plan to assist the client in maintaining self-care abilities?

break down activities into small steps rationale it is often necessary to break down ADLs such as dressing into small steps and explain what is happening at each step in very specific and simple terms. large group and complex activities should be avoided when clients have Parkinson's disease and dementia, because they are likely to cause the individual to become agitated or have a catastrophic reaction (become angry and display aggressive behavior). routine is very important and it is necessary to introduce changes very slowly so the day and time of bathing should remain constant. music has a positive influence including improved capacity to communicate, reminisce and recall memories

a client experiences an episode of Bell's palsy and complains about increasing clumsiness. the nurse should prepare the client for which diagnostic study or studies to determine the cause of the complaints. select all that apply

cerebral angiography // lumbar puncture // computed tomography rationale bell's palsy can be caused by inflammation or a lesion of the facial nerve and when the client presents with both bell's palsy and increasing clumsiness, the health care team suspects more diffuse CNS lesions the most sensitive and specific tests that provide relevant diagnostic information for these types of pathology are cerebral angiography, LP, and CT. the imaging studies illustrate CNS lesions, and the LP enables the care provider to analyze CSF for immunoglobulins (antibodies) and other components.

the nurse reviews the HCP's treatment plan for a client with GBS. which prescription noted in the client's record should the nurse question?

clear liquid diet rationale clients with GBS have dysphagia. clients with dysphagia are more likely to aspirate on clear liquids than thick or semisolid foods. clients with GBS are at risk hypotension or hypertension, bradycardia, and respiratory depression and require frequent monitoring of vital signs. passive ROM exercises can help prevent contractures and checking calf measurements can help detect DVTs for which clients are at risk

the nursing instructor asks a nursing student about the points to document if the client has had a seizure. the instructor determines that the student needs to research seizures and related documentation points if the student states which assessment is important

client's diet in the 2 hours preceding seizure activity rationale typically, seizure assessment includes the time the seizure began, part(s) of the body affected, the type of movements and progression of the seizure, changes in pupil size, eye deviation or nystagmus, client condition during the seizure, and postictal status

the nurse is preparing to give the postcraniotomy client medication for incisional pain. the family asks the nurse why the client is receiving codeine sulfate and not "something stronger." the nurse should formulate a response based on which understanding of codeine?

codeine does not alter respirations or mask neurological signs as do other opioids. rationale codeine sulfate is the opioid analgesic often used for clients after craniotomy. it is frequently combined with a nonopioid analgesic such as acetaminophen for added effect. it does not alter the respiratory rate or mask neurological signs as do other opioids. side effects of codeine include gastrointestinal upset and constipation. the medication can lead to physical and psychological dependence with chronic use. it is not the strongest opioid analgesic available

a client has a halo vest that was applied following a C6 spinal cord injury. the nurse performs which action to determine whether the client is ready to begin sitting up?

compares the client's pulses and blood pressure when both flat and sitting rationale clients with cervical spinal cord injuries may lose control over peripheral vasoconstriction, causing postural hypotension when upright. a drop of 15mmHg in the systolic pressure or 10mmHg in the diastolic pressure accompained by an increase in heart rate when the head is elevated may indicate autonomic insufficiency that can cause dizziness or syncope in the upright position. assessment of skin integrity of the pin sites is important but does not affect sitting readiness. hip range of motion is not affected initially in this type of cord injury. the halo vest is not loosened by the nurse; the vest provides trunk stability for sitting.

the client with a cervical spine injury has Crutchfield tongs applied in the ED. the nurse should perform which essential action when caring for this client?

comparing the amount of prescribed weights with the amount in use rationale Crutchfield tongs are applied after drilling holes in the client's skull under local anesthesia. weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. the nurse ensures that weights hang freely and that the amount of weight matches the current prescription. the client with Crutchfield tongs is placed on a stryker frame or roto-rest bed. the nurse does not remove the weights to administer care or change the level of tension or traction based on client comfort level

the nurse is trying to communicate with a stroke (brain attack) client with aphasia. which action by the nurse would be least helpful to the client?

completing the sentences that the client cannot finish rationale clients with aphasia after stroke often fatigue easily and have a short attention span. general guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. the nurse should avoid shouting (because the client is not deaf), appearing impatient for a repsonse, and completing responses for the client

the nurse caring for a client following a craniotomy monitors for signs of ICP. which indicates an early sign of ICP?

confusion rationale early signs/symptoms of ICP are subtle and may often be transient, lasting for only a few minutes in some cases. these early clinical signs/symptoms include changes in LOC including episodes of confusion and drowsiness, and slight pupillary and breathing changes. clincal signs/symptoms of later ICP include decreasing LOC, a widened pulse pressure, and bradycardia. cheyne-stokes respiratory pattern, or a hyperventilation respiratory pattern, and sluggish and dilating pupils appear in the later stages

the nurse is collecting data on a client diagnosed with PD. which finding indicates a serious complication of this disorder

congested cough and course rhonchi heard during auscultation rationale clients with PD are at risk for aspiration. a congested cough and coarse rhonchi may be present after a client aspirates. although constipation is a problem for clients with PD, the concern is greater if the client has not had a bowel movement by the third day. resting and pill-rolling tremors and a shuffling, propulsive gait are characteristic findings in PD

a client with Parkinson's disease "freezes" while ambulating, increasing the risk for falls. which suggestion should the nurse include in the client's plan of care to alleviate the problem?

consciously think about walking over imaginary lines on the floor rationale clients with PD can develop bradykinesia (slow movement) or akinesia (freezing or no movement). having these individuals imagine lines on the floor to step over can keep them moving forward. although standing erect and using a cane can help prevent falls, these measures will not help a person with akinesia move forward. clients with PD should walk with a wide gait, not with the feet close together. a wheelchair should be used only when the client can no longer ambulate with assistive devices such as canes or walkers.

an adult client with suspected meningitis has undergone a lumbar puncture to obtain CSF for analysis of a bacterial infection. the nurse checks for which value indicating a bacterial infection of the CSF

decreased glucose level rationale findings that indicate a bacterial infection of the CSF include presence of a bacterial organism, elevated WBC count, elevated protein level and decreased glucose level. RBC should not be present in CSF.

a client who sustained a closed head injury has a new onset of copious urinary output. urine output for the previous 8 hour shift was 3300 mL and 2800 mL for the shift before that. the findings have been reported to the HCP, and the nurse anticipates a prescription for which medication?

desmopressin (DDAVP) rationale a complication of closed head injury is diabetes insipidus (DI). this may occur if the injury affects the hypothalamus, antidiuretic hormone storage vesicles, or the posterior pituitary gland. urine output that exceeds 9 L/day generally requires treatment with DDAVP an antidiuretic. ethacrynic acid and mannitol are both diuretics, which would be contraindicated for this client. dexamethasone is a glucocorticoid that is used to treat cerebral edema. this medication already may be prescribed for the head-injured client but does not relate to DI

the nurse is preparing for the admission of the client with a suspected diagnosis GBS. which sign/symptoms is considered a primary symptom of this syndrome?

development of muscle weakness rationale a hallmark symptom of GBS is muscle weakness that develops rapidly. the client does not have symptoms such as a fever or headache. cerebral function, LOC, and pupillary responses are normal. seizures are not normally associated with this disorder.

a client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. the nurse determines that the client will derive the least muscle-strengthening benefit from which activity

doing active ROM to finger joints rationale ROM exercises of the finger joints prevent contractures but do not actively strengthen muscle groups needed for self-mobilization with paraplegia. other activities that are more effective include push-ups from a prone position, sit-ups from a sitting position, extending the arms while holding weights, and squeezing rubber balls or crumpling newspaper

the nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. this conclusion is based on which findings? select all that apply

drainage from ear // bruising around the eyes // pink-tinged drainage from the nose rationale drainage from ear or nose (clear or pink-tinged) is an indicator of the presence or CSF which could be leaking as a result of the skull fracture. bruising around the eyes (raccoon sign) is also an indicator of basilar skull fractures. tachycardia, coughing, and lower back pain are not associated specifically with skull fractures

the nurse is caring for a client with an intracranial aneurysm who was previously alert. which finding should be an early indication that the LOC is deteriorating?

drowsiness rationale early changes in LOC relate to orientation, alertness, and verbal responsiveness. less frequent speech, slight slurring of speech, and mild drowsiness are early signs of decreasing LOC. Ptosis of the eyelid is due to pressure on and dysfunction of cranial nerve III and does not relate to LOC

the nurse is admitting a client with Guillain-Barre Syndrome to the nursing unit. the client has an ascending paralysis to the level of the waist. knowing the complications of the disorder, the nurse should bring which items into the client's room?

electrocardiographic monitoring electrodes and intubation tray rationale the client with GBS is at risk for respiratory failure because of ascending paralysis. an intubation tray should be available for use. another complication of this syndrome is cardiac dysrhythmia, which necessitates the use of ECG monitoring. because the client is immobilized, the nurse should routinely assess for DVTs and PEs

the nurse is caring for a client who sustained a spinal cord injury. while administering morning care, the client developed signs and symptoms of autonomic dysreflexia. which is the initial nursing action?

elevate the head of the bed rationale autonomic dysreflexia is a serious complication that can occur in the spinal cord of the injured client. once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. the nurse also assesses the client's blood pressure, but the initial action is to elevate the head of the bed. the client should be placed in the prone position

a client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. the nurse should plan which approach as therapeutic in assisting the client to cope with the disease?

encourage and praise perseverance in exercising and performing ADL rationale the client with Parkinson's disease tends to become withdrawn and depressed and therefore should become an active participant in his or her own care to prevent this. activities should be planned throughout the day to inhibit daytime sleeping and boredom. the nurse gives the client encouragement and praises the client for perseverance. activities such as exercise help prevent progression of the disease, and self-care improves self-esteem.

the nurse is planning care for a client who displays confusion secondary to a neurological problem. which approach by the nurse would be least helpful in assisting this client?

encouraging multiple visitors at one time rationale clients with cognitive impairment from neurological dysfunction respond best to a stable environment, which is limited in the amounts and type of sensory input. the nurse can provide sensory cues and give clear, simple directions in a positive manner. confusion and agitation can be minimized by reducing environmental stimuli (such as television, multiple visitors) and keeping familiar personal articles (such as family pictures) at the bedside.

a client with right leg hemiplegia is experiencing difficulty with mobility. the nurse determines that the family needs reinforcement of teaching if the nurse observes which action by the family?

encouraging the client to stand unassisted on the leg rationale the question is worded to elicit an unsafe action on the part of the family. depending on the client's functional ability, either passive or active ROM is indicated to keep the joint moving freely. application of a premolded splint would also keep the limb aligned and in good position. the client should not attempt to stand unsupported on a weak or paralyzed limb. the inability to bear weight will cause the client to fall.

a client with a neurological impairment experiences urinary incontinence. which nursing action should help the client adapt to this alteration?

establishing a toileting schedule rationale a bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. a foley catheter should be used only when necessary because of risk of infection. use of diapers or pads is the least acceptable alternative because the risk of skin breakdown exists.

a client is somewhat nervous about having an MRI. which statement by the nurse should provide reassurance to the client about the procedure?

even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure rationale the MRI scanner is a hollow tube, which gives some clients a feeling of claustrophobia. metal objects must be removed before the procedure so that they are not drawn into the magnetic field. the client may eat and take all prescribed medications before the procedure. if a contrast medium is used, the client may wish to eat lightly if there is a tendency to get nauseated easily. the client lies supine on a padded table, which moves into the imager. the client must lie still during the procedure. the imager makes tapping noises while scanning. the client is alone in the imager, but the nurse can reassure the client that the technician is in voice communication with the client at all times during the procedure.

the nurse is caring for a client diagnosed with Bell's palsy 1 week ago. which data would indicate a potential complication associated with Bell's palsy?

excessive tearing rationale complications of Bell's palsy include abnormal return of nerve function; corcodile tears (autonomic fibers reconnect to the lacrimal duct instead of the salivary glands, so the client develops excessive tearing while eating); abnormal facial movements because of reinnervation of inappropriate muscles; and spasms, atrophy, and contractures caused by incomplete motor fiber reinnervation. partial facial paralysis is a factor indicating recovery. negative outcomes on the electromyography performed 1 week after symptom onset indicate that nerve function is present (a negative test indicates a positive prognostic outcome) tasting food 1 week after symptom onset indicates a good prognosis for recovery

the client recovering from a head injury is arousable and participating in care. the nurse determines that the client understands measures to prevent elevations in ICP if the nurse observes the client doing which activity

exhaling during repositioning rationale activities that increase intrathoracic and intraabdominal pressures cause indirect elevation of the ICP. some of these activities include isometric exercises, valsalva maneuver, coughing, sneezing, and blowing the nose. exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising

the nurse is trying to help the family of an unconscious client cope with the situation. which intervention should the nurse plan to incorporate into the care routine for the client?

explaining equipment and procedures on an ongoing basis rationale families often need assistance to cope with the sudden, severe illness of a loved one. the nurse can help the family of an unconscious client by assisting them to work through their feelings of grief. the nurse should explain all equipment, treatments, and procedures and supplement or reinforce information given by the HCP. the family should be encouraged to touch and speak to the client and to become involved in the clients care to the extent that they are comfortable. the nurse should allow and should encourage them to eat and sleep adequately to maintain their strength.

the nurse is assisting in gathering data on cranial nerve XII of a client who sustained a brain attack (stroke). the nurse understands that the client should be asked to perform which action?

extend the tongue rationale to assess the function of cranial (hypoglossal) nerve XII, the nurse would assess client's ability to extend the tongue.

which sign/symptom is observed in the clonic phase of a seizure

extension spasms of the body rationale the clonic phase of a seizure is characterized by violent extension spasms of the entire body interrupted by muscular relaxation and accompanied by strenuous hyperventilation. the face is contorted and the eyes roll. there is excessive salivation resulting in frothing from the mouth, biting of the tongue, profuse sweating, and a rapid pulse. the clonic jerking subsides by slowing in frequency and losing strength over a period of 30 seconds.

the nurse is assigned to care for an adult client who had a stroke and is aphasic. which interventions should the nurse use for communicating with the client? select all that apply

face the client when talking // speak slowly and maintain eye contact // use gestures when talking to enhance words // give the client directions using short phrases and simple terms rationale a client who is aphasic has difficulty expressing or understanding language. the nurse should face the client when talking, establish and maintain eye contact, and speak slowly and distinctly. the nurse should use gestures and pantomime when talking to enhance words and use body language to enhance the message. the nurse should give the client directions using short phrases and simple terms, and phrase questions so that they can be answered with a yes or no. if there is a need to repeat something, the nurse should use the same words a second time.

the nurse is preparing for the admission of a client with a diagnosis of early stage Alzheimer's disease. the nurse assists in developing a plan of care, knowing that which is a characteristic of early Alzheimer's disease?

forgetfullness rationale in early AD, forgetfullness begins to interfere with daily routines. the client has difficulty concentrating and difficulty learning new material.

a client with GBS has been asking many questions about the condition, and the nursing staff feels that the client is very discouraged about her condition. it is important for the nurse to include which information in discussions with the client?

generally, a vast number of people recover from this condition rationale the vast majority of clients with GBS recover from the paralysis because it affects peripheral nerves that have the capacity to remyelinate. maximum paralysis can take up to 4 weeks to develop. paralysis progresses distally to proximally. rehab can take from 6 months to 2 years

a client with a stroke (brain attack) has residual dysphagia. when a diet prescription is initiated, the nurse should avoid which action?

giving the client thin liquids rationale before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. the client is assisted with meals as needed and is given ample time to chew and swallow. food is placed on the unaffected side of the mouth. liquids are thickened to avoid aspiration.

the nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. the nurse determines that the client needs further teaching if the client makes which statements?

going to the beach will be a nice, relaxing form of activity rationale most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client needs to be aware of the lifestyle changes needed to maintain independence. taking medications 1 hour before mealtime gives greater muscle strength for chewing and is indicated. the client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. the client should carry medical identification about the condition. the client should avoid activities that could worsen the symptoms, including stress, infection , heat, surgery, or alcohol.

the nurse has given medication instructions to the client receiving phenytoin (Dilantin). the nurse determines that the client understands the instructions if the client makes which comment?

good oral hygiene is needed, including brushing and flossing rationale typical anticonvulsant medication instructions include taking the prescribed dose daily to keep the blood level of the drug constant, having a serum drug level drawn before taking the morning dose, avoiding abruptly stopping the medication, avoiding alcohol, checking with the HCP before taking over-the-counter medications, avoiding activities in which alertness and coordination are required until medication effects are known, providing good oral hygiene and getting regular dental care, and wearing a Medic-Alert bracelet or tag

the nurse notices that a client with trigeminal neuralgia has been withdrawn, is having frequent episodes of crying, and is sleeping excessively. which method is the best way for the nurse to explore issues with the client regarding these behaviors?

have the client express the feelings in writing rationale speaking can exacerbate the pain that occurs with trigeminal neuralgia. having the client record feelings in writing will help the nurse gain an understanding of the client's concerns without increasing the client's pain. discussing the issue with the family will not provide insight into the client's feelings. it is not in the client's best interest to refer the matter to the HCP or to ignore the behavior. the nurse should explore the client's concerns and offer support.

a female client with MG comes to the HCP's office for as scheduled office visit. the client is very concerned and tells the nurse that her husband seems to be avoiding her because she is very unattractive. which is the appropriate nursing response?

have you thought about sharing your feelings with your husband? rationale encouraging the client to share feelings with her husband directly addresses the subject of the question. advising the client to join a support group will not address the client's immediate and individual concerns.

the nurse is caring for a client who has undergone craniotomy with a supratentorial incision. the nurse should plan to place the client in which position postoperatively

head of bed elevated 30 to 45 degrees, head and neck midline rationale following supratentorial surgery, the head of the bed is kept at a 30 - to - 45 degree angle. the head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. this will promote venous return through the jugular veins, which will help prevent a rise in ICP

the nurse has applied a hypothermia blanket to a client with a fever. the nurse should inspect the skin frequently to detect which complication of hypothermia blanket use?

skin breakdown rationale when a hypothermia blanket is used, the skin is inspected frequently for pressure points that over time could lead to skin breakdown.

the nurse observes the UAP positioning the client with ICP. which position would require intervention by the nurse?

head turned to the side rationale the head of the client with increased ICP should be positioned so that the head is in a neutral, midline position. the nurse should avoid flexing or extending the neck or turning the head side to side. the head of the bed should be raised to 30 to 45 degrees. use of proper positions promotes venous drainage from the cranium to keep ICP down.

a client with suspected GBS has a lumbar puncture performed. the CSF protein is 750 mg/dL. the nurse analyzes these results as which?

higher than normal, supporting the diagnosis of Guillain-Barre rationale 7-10 days following the onset of symptoms of Guillain-Barre, the spinal fluid protein levels become extremely high. normal CSF protein is 15 to 45 mg/dL a value of 750 mg/dL is higher than normal supporting the diagnosis of Guillain-Barre

the nurse suspects neurogenic shock in a client with complete transection of the spinal cord at the T3 level if which clinical symptoms are observed?

hypotension and bradycardia rationale spinal cord transection at the T5 level or above may lead to neurogenic shock. this injury results in massive vasodilation without compensation because of the loss of sympathetic nervous system vasoconstriction tone. as a result, hypotension and bradycardia will be manifested. hypertension with either bradycardia or tachycardia would not be exhibited

the nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. the nurse understands that there may be damage to the clients thermoregulatory center which is located in which part of the brain

hypothalamus rationale hypothalamic damage causes hyperthermia, which may also be called "central fever" it is characterized by a persistent high fever with no diurnal variation. there is also an absence of sweating.

a client seeking treatment for an episode of hyperthermia is being discharged to home. the nurse determines that the client needs clarification of discharge instructions if the client makes which statement?

i can resume a full activity level immediately rationale discharge instructions for the client hospitalized for hyperthermia include prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting

the nurse is collecting data on a client with myasthenia gravis. the nurse determines that the client may be developing myasthenic crisis if the client makes which statement?

i can't swallow very well today rationale because dysphagia is a classic sign of MG exacerbation, observing how a client is able to ingest food is an important assessment. timing of this medication is of paramount concern.

the nurse is reinforcing discharge instructions to a client who has undergone transsphenoidal surgery for a pituitary adenoma. which statement by the client indicates the client understands the discharge instructions

i need to call the doctor if i develop frequent swallowing or postnasal drip rationale the client should report frequent swallowing or postnasal drip after transsphenoidal surgery because it could indicate CSF leakage. the surgeon removes the nasal packing, usually after 24 hours. the client should deep breathe, but coughing is contraindicated because it could cause increased ICP. the client should report a severe headache because it could indicate increased ICP

the nurse is reinforcing instructions to the client who has just been fitted for a halo vest. which statement by the client indicates the need for further teaching

i will avoid driving at night because the vest limits the ability to turn the head rationale the client wearing a halo vest should not drive at all because the device impairs head movement and the range of vision. the inability to turn the head without turning the torso would make driving contraindicated. the halo device does alter balance and can pose increased risk of falls for the client. the client should clean the skin daily under the vest to protect the skin from ulceration and should use powder or lotions sparingly or not at all. the client should have food cut into small pieces to facilitate chewing and use straws for drinking because the head immobilization makes eating and drinking harder.

a halo vest is applied to a client following a cervical spine fracture. the nurse reinforces instructions to the client regarding safety measures related to the vest. which statement by the client indicates a need for further teaching?

i will bend at the waist, keeping the halo vest straight to pick up items rationale the client with a halo vest should avoid bending at the waist because the halo vest is heavy and the client's trunk is limited in flexibility. it is helpful for the client to scan the environment visually because the client's peripheral vision is diminished from keeping the neck in a stationary position. use of a walker and rubber-soled shoes may help prevent falls and injury so these items are also helpful.

the nurse has provided discharge instructions to a client with an application of a halo device. the nurse determines that the client needs further teaching if which statement is made

i will drive only during the daytime rationale the client should not drive because the device impairs the range of vision. the halo device alters balance and can cause fatigue because of its weight. the client should cleanse the skin daily under the vest or the device to protect the skin from ulceration and should use powder or lotions sparingly or not at all. the wool liner should be changed if odor becomes a problem. the client should have food cut into small pieces to facilitate chewing and use a straw for drinking. pin care is done as instructed

the nurse reinforces home care instructions to the postcraniotomy client. which statement by the client indicates the need for further teaching

i will not hear sounds clearly unless they are loud rationale seizures are a complication that can occur for up to 1 year after surgery. for this reason, the client must diligently take anticonvulsant medications. the client and family are encouraged to keep track of doses administered. the family should learn seizure precautions and accompany the client while ambulating if dizziness or seizures tend to occur. the suture line is kept dry until sutures are removed to prevent infection. the postcraniotomy client can hear sounds, is typically sensitive to loud noises, and can find them irritating. awareness control of environmental noise by others is helpful to this client

which data collection finding supports the possible diagnosis of bell's palsy?

speech or chewing difficulties accompanied by facial droop rationale bell's palsy is a one-sided facial paralysis from compression of cranial nerve VII (facial) VII. there is facial droop from paralysis of the facial muscles, increased lacrimation, and speech or chewing difficulty.

the nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. the nurse determines that the client needs further teaching if the client made which statement?

i will try to eat my food either very warm or very cold rationale facial pain can be minimized by using cotton pads and room temperature water to wash the face. the client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. if toothbrushing triggers pain, sometimes an oral rinse after meals is more helpful.

a resident in a long-term care facility prepares to walk out into a rainstorm after saying my father is waiting to take me for a ride. an appropriate response by the nurse is which?

i'm glad you told me that. let's have a cup of coffee and you can tell me about your father rationale the correct response acknowledges the client's comment and feelings.

a client with Parkinson's disease is experiencing a parkinsonian crisis. the nurse should immediately place the client where?

in a quiet, dim room with respiratory and cardiac support available rationale parkinsonian crisis can occur with emotional trauma or sudden withdrawal of medications. the client exhibits severe tremors, rigidity, and bradykinesia. the client also displays anxiety, is diaphoretic, and has tachycardia and hyperpnea. the client should be placed in a quiet, dim room and respiratory and cardiac support should be available

the nurse is caring for a client with a diagnosis of brain attack (stroke) with anosognosia. to meet the needs of the client with this deficit, which action does the nurse plan?

increase the client's awareness of the affected side rationale in anosognosia, the client neglects the affected side of the body. the nurse should plan care activities that encourage the client to look at the affected arm or leg and that will increase the client's awareness of the affected side.

the nurse is caring for a client with increased intracranial pressure (ICP). which change in vital signs would occur if ICP is rising?

increasing temperature, decreasing pulse, decreasing respirations, increasing BP rationale a change in vital signs may be a late sign of increased ICP. trends include increasing temperatures and BP and decreasing pulse and respirations. respiratory irregularities may also arise.

the nurse notes documentation that a postcraniotomy client is having difficulty with body image. the nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance?

indicates that facial puffiness will be a permanent problem rationale after craniotomy, the client may experience difficulty with altered personal appearance. the nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising and hair loss, which are temporary. the nurse can encourage the client to participate in self-grooming and use personal articles of clothing. finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt ot the temporary change in appearance

the family of an unconscious client with increased intracranial pressure is talking at the client's bedside. they are discussing the gravity of the clients condition and wondering if the client will ever recover. how should the nurse interpret the clients situation

it is possible the client can hear the family rationale some clients who have awakened from an unconscious state report that they remember hearing specific voices and conversations. family and staff should assume that the clients sense of hearing is still intact and act accordingly. research has also demonstrated that positive outcomes are associated with coma stimulation, that is, speaking to and touching the client

the client with spinal cord injury is prone to experiencing autonomic dysreflexia. the least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

limiting bladder catheterization to once every 12 hours rationale the most frequent cause of autonomic dysreflexia is a distended bladder. straight catheterization should be performed every 4 to 6 hours, and indwelling bladder catheters should be checked frequently for kinks in tubing. it is not appropriate to catheterize the client every 12 hours. constipation and fecal impaction are other causes, so maintaining bowel regularity is important. other causes include stimulation of the skin from tactile, thermal, or painful stimuli. the nurse administers care to minimize risk in these areas.

a client with myasthenia gravis is having difficulty speaking. the client's speech is dysarthric and has a nasal tone. the nurse should use which communication strategies when working with this client select all that apply

listening attentively // asking yes and no questions when able // using a communication board when necessary // repeating what the client said to verify the message rationale the client has speech that is nasal in tone and dysarthric because of cranial nerve involvement of the muscles governing speech. the nurse listens attentively and verbally, verifies what the client has said, asks questions requiring a yes or no response, and develops alternative communication methods. encouraging the client to speak quickly is an ineffective communication strategy and is counterproductive

the nurse is reinforcing instructions to a client taking divalproex sodium (Depakote). the nurse tells the client to return to the clinic for follow-up laboratory studies related to which test?

liver function studies rationale divalproex sodium, an anticonvulsant, can cause hepatotoxicity which is potentially fatal. the nurse instructs the client to return to the clinic for follow-up liver function studies, such as lactate dehydrogenase (LDH) serum glutamic-oxaloacetic transaminase (SGOT), serum glutamate pyruvate transaminase (SGPT) and ammonia levels. this is especially indicated in the first 6 months of therapy.

the nurse is caring for the client who has suffered spinal cord injury. the nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted

severe, throbbing headache rationale the client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. it is characterized by a severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. other signs include nasal stuffiness, blurred vision, nausea, and sweating. it is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury

the nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. which item should be included as part of the precautions?

maintaining the head of the bed at 15 degrees rationale aneurysm precautions include placing the client on bed rest with the head of the bed elevated in a quiet setting. lights are kept dim to minimize environmental stimulation. any activity such as pushing, pulling, sneezing, coughing, or straining that increases blood pressure or impedes venous return from the brain is prohibited. the nurse provides all physical care to minimize increases in blood pressure. for the same reason, visitors, radio, television, and reading materials are prohibited or limited. stimulants such as caffeine and nicotine are prohibited; decaffeinated coffee or tea may be given.

the nurse is suctioning an unconscious client who has a tracheostomy. the nurse should avoid which action during this procedure?

making sure not to suction for longer than 30 seconds rationale suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is present. the nurse auscultates breath sounds every 2 to 4 hours, or more frequently if there is a need. the client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. the client should not be suctioned for longer than 10 seconds at one time to prevent cerebral hypoxia and an increase in intracranial pressure

the nurse observes that a client with Parkinson's disease has very little facial expression. the nurse attributes this piece of data to which information?

masklike facies is a component of Parkinson's disease rationale a masked facial expression is typical of the client with Parkinson's disease.

a client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. how should the nurse interpret this?

meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable. rationale depression is frequently seen in the client with spinal cord injury and may be exhibited as a loss of appetite. the client should be allowed to choose the types of food eaten and to eat as much as is feasible because it is one of the few areas of control that the client has left.

the nurse is reviewing the medical record of a client diagnosed with amyotrophic lateral sclerosis (ALS). which initial sign/symptom of this disorder supports this diagnosis?

mild clumsiness rationale the initial manifestation of ALS is a mild clumsiness usually in the distal portion of one extremity. the client may complain of tripping and may drag one leg when the lower extremities are involved. mentation and intellectual function are usually normal. diminished gag reflex and muscle wasting are not initial clinical sign/symptoms.

the client was seen and treated in the emergency department for a concussion. before discharge, the nurse explains the signs/symptoms of a worsening condition. the nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom

minor headache rationale a concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. after concussion, the family is taught to monitor the client and call the HCP or return the client to the ED if certain signs and symptoms are noted. these include confusion, difficulty awakening or speaking, one-sided weakness, vomiting, or severe headache. minor headache is expected

a thymectomy via a median sternotomy approach is performed on a client with a diagnosis of myasthenia gravis. the nurse has assisted in developing a plan of care for the client and includes which nursing action in the plan?

monitor the chest tube drainage rationale a thymectomy may be performed to improve the condition in clients with MG. the procedure is performed by a median sternotomy or a transcervical approach. postoperatively, the client will have a chest tube in the mediastinum. pain medication is administered as needed, but the client is monitored closely for respiratory depression. lactated ringers IV solutions are usually avoided because they can increase weakness. there is no reason to restrict visitors

the nurse develops a plan of care for a client following a lumbar puncture. which interventions should be included in the plan? select all that apply.

monitor the client's ability to void // maintain the client in a flat position // monitor client's ability to move extremities // inspect puncture site for swelling, redness and drainage rationale following a lumbar puncture, the client remains flat in bed for 6 to 24 hours, depending on the HCP's prescriptions. a liberal fluid intake (not NPO status) is encouraged to replace CSF removed during the procedure, unless contraindicated by the client's condition. the nurse checks the puncture site for redness and drainage and monitors the client's ability to void and move the extremities.

a client is admitted to the emergency department with a C4 spinal injury. the nurse performs which intervention first when collecting data on the client?

monitoring the respiratory rate rationale because compromise of respirations is a leading cause of death in cervical spinal cord injury, respiratory assessment is the highest priority. assessment of temperature and strength can be done after adequate oxygenation is assured. dyskinesia occurs in cerebellar disorders, so it is not important in cord-injured clients, unless a head injury is suspected.

the nurse is planning care for a client in spinal shock. which action would be least helpful in minimizing the effects of vasodilation below the level of the injury

moving the client quickly as one unit rationale reflex vasodilation below the level of spinal cord injury places the client at risk of orthostatic hypotension, which may be profound. actions to minimize this include measuring vital signs before and during postural changes, use of a tilt table in early mobilization, and changing the clients position slowly. venous pooling can be reduced by using compression stockings, if prescribed. vasopressor medications are used as per protocol and as prescribed

a client is about to undergo a LP. the nurse tells the client that which position will be used during the procedure?

side-lying with legs pulled up and the head bent down onto the chest rationale the client undergoing LP is positioned lying on the side, with the legs pulled up to the abdomen and with the head bent down onto the chest. this position helps open the spaces between the vertebrae and allows for easier needle insertion by the HCP.

a client receives a dose of edrophonium (Enlon). the client shows improvement in muscle strength for a period of time following the injection. the nurse should interpret this finding as indicative of which disease process?

myasthenia gravis rationale myasthenia gravis can often be diagnosed based on clinical signs and symptoms. the diagnosis can be confirmed by injecting the client with a dose of edrophonium. this medication inhibits the breakdown of an enzyme in the neuromuscular junction, so more acetylcholine binds to receptors. if the muscle is strengthened for 3 to 5 minutes after this injection, it confirms a diagnosis of myasthenia gravis. another medication, neostigmine (Prostigmin) also may be used because its effect lasts for 1 to 2 hours, providing a better analysis. for either medication, atrophine sulfate should be available as the antidote.

a client recovering from a craniotomy complains of a "runny nose." based on the interpretation of the client's complaint, which action should the nurse take?

notify the RN rationale if the client has sustained a craniocerebral injury or is recovering from a craniotomy, careful observation of any drainage from the eyes, ears, nose or traumatic area is critical. CSF is colorless and generally nonpurulent, and its presence is indicative of a serious breach of cranial integrity. the nurse would check the drainage for the presence of glucose, which would be indicative of the presence of CSF and would report the presence of any suspicious drainage to the RN, who would then contact the HCP

a client is recovering at home after suffering a stroke 2 weeks ago. a home caregiver tells the home health nurse that the client has some difficulty swallowing foods and fluids. which nursing action would be appropriate?

observe the client feeding himself or herself rationale it is not uncommon for a client to have difficulty swallowing after having a stroke. often the client has hemiplegia. the client's arm may be paralyzed, and the client has to learn to use an opposite arm to feed himself or herself. using a different arm may require rehabilitation and retraining. also a client may have partial paralysis of the mouth, tongue, or esophagus. to best assist the client, the nurse should first assess the situation by watching the client feed himself or herself. perhaps the problem lies in the feeding technique, the type of feeding tool used, the types of foods being served, or combination of problems. having someone else feed the client may be necessary if the client is determined to be unable to feed himself or herself, but this action does not promote independence in the client. a feeding syringe is not recommended for feeding most clients.

a client has experienced an episode of myasthenic crisis. the nurse collects data to determine whether the client has experienced which precipitating factor?

omitted doses of medication rationale myasthenic crisis is often caused by undermedication and responds to administration of cholinergic medications such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. too little exercise and fatty food intake are incorrect options. overexertion and overeating could trigger myasthenic crisis.

a client with a seizure disorder is being admitted to the hospital. which should the nurse plan to implement for this client? select all that apply

pad the bed's side rails // place an airway at the bedside // place oxygen equipment at bedside // place suction equipment at the bedside rationale the nurse should plan seizure precautions for a client with a seizure disorder. the precautions include padded side rails and an airway and oxygen and suction equipment at the bedside. attempts to force a padded tongue blade between clenched teeth may result in injury to the teeth and mouth; therefore a padded tongue blade is not placed at the bedside.

a client with a stroke is experiencing residual dysphagia. the nurse should remove which food items that arrived on the client's meal tray from the dietary department

peas rationale in general, flavorful, very warm or well-chilled foods with texture stimulate the swallowing reflex. moist pastas, casseroles, egg dishes and potatoes are usually well tolerated. raw vegetables, chunky vegetables such as diced beets and stringy vegetables such as spinach, corn, and peas are commonly excluded from the diet of a client with a poor swallowing reflux

the nurse is collecting admission data on a client with PD. the nurse asks the client to stand with feet together and the arms at the size and then to close to the eyes. the nurse notes that the client begins to fall when the eyes are closed. based on this finding, the nurse documents which in the client's record?

positive romberg's test rationale romberg's test checks for cerebellar functioning related to balance. the client stands with the feet together and the arms at the side and then closes the eyes. slight swaying is normal, but loss of balance indicates a problem and a positive romberg's test. trousseau's sign indicates a calcium imbalance.

a client has just undergone an LP. the nurse assists the client into which optimal position?

prone, with a pillow under the abdomen rationale if it can be tolerated by the client, the optimal position following LP is prone with a small pillow under the abdomen. this position helps minimize or prevent continued leakage of CSF from the site by enlisting the aid of gravity. if the client cannot tolerate this position, the client should be positioned flat in bed and turned from side to side as necessary. it is important that the head of bed remain flat to prevent CSF leakage and to prevent postprocedure headache

a client admitted to the hospital with a neurological problem indicates to the nurse that MRI may be done. which finding noted in the client history indicates that the client may be ineligible for this diagnostic procedure?

prosthetic valve replacement rationale the client having an MRI must have all metallic objects removed because of the magnetic field generated by the device. a careful history is done to determine if any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. these may heat up, become dislodged, or malfunction during this procedure. the client may be ineligible if there is significant risk

a client has an impairment of cranial nerve II. Specific to this impairment, the nurse plans to do which to ensure client safety?

provide a clear path for ambulation without obstacles rationale cranial nerve II is the optic nerve, which governs vision. the nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. testing the shower water temperature would be useful if there were impairment of peripheral nerves. speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior one third of the tongue, respectively

the nurse is planning to institute seizure precautions for a client who is being admitted from the ED. which measure should the nurse avoid in planning for the clients safety

putting a padded tongue blade at the head of the bed rationale seizure precautions may vary somewhat from agency to agency, but they generally have some commonalities. usually airway, oxygen, and suctioning equipment are kept available at the bedside. the side rails of the bed are padded, and the bed is kept in the lowest position. the client should have an IV access in place to have a readily accessible route if anticonvulsant medications must be administered. the use of padded tongue blades is no longer best practice, and they should not be kept at the bedside. forcing a tongue blade into the mouth during a seizure will more likely harm the client who bites down during seizure activity. other risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. if the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins

the client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. after checking vital signs, which immediate action should the nurse take

raise the head of the bed and remove the noxious stimulus rationale key nursing actions are to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol. the nurse can also clearly label the client's chart identifying the risk for autonomic dysreflexia. client and family should be taught to recognize, and later manage, the signs and symptoms of this syndrome.

the nurse is collecting data on a client suspected of having Alzheimer's disease. the priority data should focus on which characteristic of this disease?

recent memory loss rationale dementia is the hallmark sign of AD. recent memory loss is one characteristic. others include problems with abstract thinking, problems with speech (not hearing) and difficulty in performing familiar tasks

the nurse is providing care to a client with ICP. which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? select all that apply

reducing environmental noise // maintaining a calm atmosphere // allowing the client uninterrupted time for sleep rationale nursing interventions should be spaced out over the shift to minimize the risk of a rise in ICP. if possible, activities known to raise ICP should be avoided when possible. other interventions to control the ICP include keeping the lighting in the room dim or off; maintaining a calm, quiet environment; and avoiding emotional stress and interruption of sleep

the nurse is monitoring a client with a spinal cord injury who is experiencing spinal shock. which assessment will provide the nurse with the best information about recovery from the spinal shock?

reflexes rationale arflexia characterizes spinal shock; therefore, reflexes should provide the best information. vital signs changes are not consistently affected by spinal shock

the nurse is reinforcing instructions to the family of a stroke client who has homonymous hemianopsia about measures to help the client overcome the deficit. the nurse determines that the family understands the measures to use if they state that they will do which?

remind the client to turn the head to scan the lost visual field rationale homonymous hemianopsia is loss of half of the visual field. the client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse should approach the client from the intact side. the nurse instructs the client to scan the environment to overcome the visual deficit and performs client teaching from within the intact field of vision. the nurse encourages the use of personal eyeglasses if they are available

a client who suffered a cervical spine injury had crutchfield tongs applied in the ED. the nurse should avoid which action in the care of the client?

removing the weights when repositioning the client rationale crutchfield tongs are a method of skeletal traction used with cervical spine injury. all of the principles of assessment and care that apply to this client. the nurse should not remove the weights to administer care; removing the weights will disrupt the traction applied. the nurse should ensure that weights hang freely and that the amount of weight matches the current prescription. the nurse should inspect the integrity and position of the ropes and pulleys. the client is placed on a stryker frame or roto-rest bed while the crutchfield tongs are in use.

the nurse is caring for a client who begins to experience seizure activity while in bed. which action by the nurse would be contraindicated?

restrain the clients limbs rationale nursing actions during a seizure include providing privacy; loosening restrictive clothing; removing the pillow and raising the padded side rails in bed; and placing the client on one side with the head flexed forward, if possible to allow the tongue to fall forward and facilitate drainage. the limbs are never restrained because the strong muscle contractions could cause the client harm. if the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head against injury; and moves furniture that may injure the client.

the nurse has given instructions to the client with Parkinson's disease about maintaining mobility. the nurse determines that the client understands the directions if the client states that he or she will perform which activity

rock back and forth to start movement with bradykinesia rationale the client with Parkinson's disease should exercise in the morning, when energy levels are highest. the client should avoid sitting in soft, deep chairs because getting up from them can be difficult. the client can rock back and forth to initiate movement. the client should buy clothes with Velcro fasteners and slide-locking buckles to allow for easier dressing.

the nurse is assisting with caring for a client after a craniotomy. which is the best position for the client to be placed?

semi-fowler's position rationale after a crainotomy, the head of the bed is elevated 30 to 45 degrees (semi-Fowler's to Fowler's position) and the client's head is maintained in a midline, neutral position to facilitate venous drainage.

the client has clear fluid leaking from the nose after a basilar skull fracture. the nurse determines that this is cerebrospinal fluid if the fluid meets which criteria?

separates into concentric rings and tests positive for glucose rationale leakage of CSF from the ears or nose may accompany a basiliar skull fracture. it can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, which is known as the halo sign. it also tests positive for glucose.

the nurse is preparing for the admission of a client with a prescription for seizure precautions. which supplies will the nurse make available to this client? select all that apply.

suction machine // oxygen administration // padding for the side rails // prescribed diazepam (Valium) rationale full seizure precautions include bed rest with padded side rails in a raised position, a suction machine at the bedside, having diazepam (Valium) or lorazepam (Ativan) available, and oxygen. objects such as tongue blades are not necessary and should never be placed in the client's mouth during a seizure.

a nursing student is collecting data on a client recently diagnosed with meningitis. the student expects to note which signs and symptoms select all that apply

tachycardia // photophobia // red, macular rash // positive Kernig's sign rationale meningitis is an infection or inflammation of the membranes covering the brain and spinal cord. signs and symptoms can include a positive kernig's sign, tachycardia red macular-type rash and photophobia. other signs and symptoms include severe headache, stiffness of the neck, irritability, malaise and restlessness. diarrhea and tinnitus are not usually associated with meningitis

the nurse is teaching the client with myasthenia gravis about prevention of myasthenic and cholinergic crises. the nurse tells the client that this is most effectively done by which activity

taking medications on time to maintain therapeutic blood levels rationale clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. it is very important to take medications correctly to maintain blood levels that are not too low or too high. muscle-strengthening exercises are not helpful and can fatigue the client. overeating is a cause of exacerbation of symptoms as are exposure to heat, crowds, erratic sleep habits, and emotional stress

the nurse is told in report that a client has a positive Chvostek's sign which other data should the nurse expect to find on data collection select all that apply

tetany // diarrhea // possible seizure activity // positive Trousseau's sign rationale focus on the subject, a positive Chvostek's sign, which is indicative of hypocalcemia. other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, seizures, positive Trousseau's sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval

the client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. the nurse expects the cervical collar will remain in place until which time?

the HCP reviews the x-ray results rationale there is a significant association between cervical spine injury and head injury. for this reason, the nurse leaves any form of spinal immobilization in place until lateral cervical spine x-rays rule out fracture or other damage and the results have been reviewed by the HCP

a client with T4 spinal cord injury is to be monitored for autonomic dysreflexia (hyperreflexia). which finding is indicative of this complication?

the client complains of a headache, and the blood pressure is elevated rationale autonomic dysreflexia, also known as autonomic hyperreflexia is a life-threatening syndrome. it is a cluster of clinical symptoms that results when multiple spinal cord autonomic response discharge simultaneously. exaggerated autonomic nervous system reactions to stimuli with severe headache. the client may sweat profusely above the level of the cord lesion and complain of a stuffy nose. the knee-jerk response is not affected. pupils may be dilated. although a distended bladder is often the precipitating event, it is not indicative of dysreflexia, and not all clients with bladder distention exhibit dysreflexia.

a client with tetraplegia complains bitterly about the nurse's slow response to the call light and the rigidity of the therapy schedule. which interpretation of this behavior should serve as a basis for planning nursing care?

the client is reacting to loss of control rationale clients who feel a sense of control over their situation will adapt to their limitations more readily than those who think that they have lost control. both of the client's complaints indicate a need for greater control. clients should be offered an opportunity for input into scheduling and planning for staff response to their needs.

the nurse is caring for a client with a diagnosis of right (nondominant) hemispheric brain attack (stroke). the nurse notes that the client is alert and oriented to time and place. based on these findings, the nurse makes which determination?

the client may have perceptual and spatial disabilities rationale the client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. these signs of apparent wellness often result in interpretations that the client is less disabled than is the case. however, impulsive actions and confusion in carrying out activities may be very much a problem for these clients, as a result of perceptual and spatial disabilities. the right hemisphere is considered specialized in sensory-perceptual and visuospatial processing and awareness of body space. the left hemisphere is dominant for language abilities.

the nurse is caring for a client with a head injury and is monitoring the client for signs of increased ICP. which sign if noted in the client should the nurse report immediately?

the client vomits rationale the client with a closed head injury is at risk of developing increased ICP. this is evidenced by symptoms such as headache, dizziness, confusion, weakness, and vomiting.

the nurse is caring for a client that is comatose and notes in the clients chart that the client is exhibiting decerebrate posturing. the nurse understands that which definition describes decerebrate posturing?

the extension of the extremities and pronation of the arms rationale posturing is a late sign of deterioration in the client's neurological status and warrants immediate HCP notification. decerebrate posturing (abnormal extension) which is associated with dysfunction in the brainstem area, is the extension of the extremities and the pronation of the arms.

the nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. which documented early symptom supports this diagnosis?

vertigo rationale early symptoms of HD include restlessness, forgetfulness, clumsiness, falls, balance and coordination problems, vertigo and altered speech and handwriting. difficulty with swallowing occurs in the later stages. aphasia and agnosia do not occur.

a client is suspected for having a diagnosis of GBS. which findings would support a diagnosis of GBS? select all that apply

visual and hearing disturbances // ascending symmetrical muscle weakness rationale GBS may affect cranial nerves resulting in visual and hearing disturbances. it is characterized by symmetrical muscle weakness that typically begins in the lower extremities and ascends to the trunk and upper extremities. approximately 95% of patients with GBS have a nearly complete recovery. despite all the motor and sensory changes, LOC and intellectual functioning remain unchanged.

a client has a cerebellar lesion. the nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?

walker rationale the cerebellum is responsible for balance and coordination. a walker would provide stability for the client during ambulation. adaptive eating utensils may be beneficial when the client has partial paralysis of the hand. a raised toilet seat is useful when the client does not have the mobility or ability to flex the hips. a slider board is used in transferring a client from a bed to stretcher or wheelchair.

a client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. the nurse determines that the client understands how to use to patch if the client states that he or she will do which?

wear the patch continuously, alternating eyes each day rationale placing an eye patch over one eye in the client with diplopia removes the second image and restores more normal vision. the patch is worn continuously and is alternated on a daily basis to maintain the strength of the extraocular muscles of the eyes

the nurse is planning care for the client with hemiparesis of the right arm and leg. where should the nurse plan to place objects needed by the client?

within the client's reach, on the left side rationale hemiparesis is a weakness of the face, arm, and leg on one side. the client with one-sided hemiparesis benefits from having objects placed on the unaffected side and within reach. other helpful activities with hemiparesis include ROM exercises to the affected side and muscle-strengthening exercises to the unaffected side